Peroneal Tendinopathy: Symptoms, Causes & Treatment

Peroneal Tendinopathy is a condition that can cause significant discomfort and limitation in movement, impacting the quality of life. This blog post by Manly Cove Podiatry aims to demystify the condition, outlining its symptoms, delving into its causes, and exploring available treatment options. By understanding Peroneal Tendinopathy, individuals can take proactive steps towards managing their symptoms and seeking effective treatment.

Understanding Peroneal Tendinopathy

Peroneal Tendinopathy is a condition characterised by damage or irritation to the peroneal tendons. These tendons run along the outside of the ankle, behind the fibula, and are crucial for stabilising the ankle and foot, and facilitating movement such as walking or running. The condition arises when the tendons become overloaded, often due to repetitive activity or an acute injury, leading to inflammation, degeneration, or tears in the tendon fibres. It is a common ailment among athletes, particularly runners, but can affect anyone.

Symptoms of Peroneal Tendinopathy

The initial signs of Peroneal Tendinopathy often include pain around the back and outside of the ankle, which may worsen with activity and improve with rest. Other symptoms can include:

  • Swelling or tenderness along the course of the peroneal tendons.
  • Pain when turning the foot in or out against resistance.
  • An increase in symptoms with activities that involve repetitive ankle motions or pressure on the tendons, such as running, jumping, or walking on uneven surfaces.

How Symptoms May Affect Daily Activities

As the condition progresses, symptoms may become more persistent, affecting everyday activities. Individuals might experience difficulty or discomfort when walking, particularly on uneven terrain, or when engaging in activities that require sudden changes in direction or speed. The stability of the ankle may also be compromised, increasing the risk of sprains or falls.

Symptoms that Differentiate it from Similar Conditions

Unlike other foot and ankle conditions, Peroneal Tendinopathy specifically causes pain and tenderness on the outer aspect of the ankle. The pain typically increases with activities that stress the tendons and decreases with rest, distinguishing it from conditions like ankle sprains or Achilles tendinopathy, which have different pain patterns and areas of tenderness.

Causes of Peroneal Tendinopathy

Peroneal Tendinopathy results from a combination of factors that stress the peroneal tendons beyond their capability to heal and adapt. The primary cause is often overuse, particularly in activities that involve repetitive ankle motion or put excessive strain on the tendons, such as running, basketball, and soccer. This repetitive stress leads to micro-tears, inflammation, and eventually degeneration of the tendon fibres if not adequately addressed.

Other contributing factors include:

  • Ankle sprains or injuries: Previous ankle injuries can weaken the tendons, making them more susceptible to tendinopathy.
  • Foot biomechanics: Individuals with high arches or varus foot (outward tilting of the heel) put additional stress on the peroneal tendons.
  • Improper footwear: Shoes that do not provide adequate support or are worn out can increase the risk.
  • Muscle imbalances: Weakness or imbalance in the muscles of the lower leg can lead to increased strain on the peroneal tendons.
  • Sudden increases in physical activity: Rapidly increasing the intensity, duration, or frequency of exercise without adequate conditioning can overload the tendons.

Understanding these causes is crucial for both prevention and treatment of Peroneal Tendinopathy, allowing for targeted interventions that address the underlying issues.

Diagnosis of Peroneal Tendinopathy

Diagnosing Peroneal Tendinopathy begins with a thorough clinical examination by a healthcare professional. During the examination, the doctor will review the patient’s medical history, particularly any incidents of ankle injuries or activities that could have led to overuse of the tendons. The physical exam involves palpating (feeling) the peroneal tendons along the outside of the ankle to identify areas of tenderness, swelling, or warmth. Functional tests, such as asking the patient to stand on their toes or perform specific movements, can help assess the tendons’ condition and the ankle’s stability.

Imaging Tests Used for Confirmation (Ultrasound, MRI)

While a clinical examination can strongly suggest Peroneal Tendinopathy, imaging tests are often used to confirm the diagnosis and assess the extent of tendon damage.

  • Ultrasound: This imaging modality is particularly useful for visualising soft tissue structures like tendons. It can show tendon thickening, tears, and inflammation. Ultrasound is also beneficial for dynamic assessment, observing the tendons’ movement in real-time.
  • MRI (Magnetic Resonance Imaging): MRI provides detailed images of the tendons and surrounding structures and can identify subtle changes in the tendon structure, tears, inflammation, and other pathologies that may not be evident on ultrasound. It’s particularly useful in diagnosing more complex cases or planning surgical intervention if needed.

Together, clinical examination and imaging tests play a crucial role in accurately diagnosing Peroneal Tendinopathy, laying the groundwork for an effective treatment plan tailored to the individual’s specific condition.

Non-Surgical Treatment Options

Initial Treatment Steps and Their Effectiveness

The primary approach to managing Peroneal Tendinopathy involves conservative, non-surgical treatment methods, especially in the early stages. The initial steps typically include:

  • Rest: Avoiding activities that aggravate the condition to allow the tendons to heal.
  • Ice: Applying ice to the affected area to reduce inflammation and pain.
  • Compression: Using compression bandages to provide support and reduce swelling.
  • Elevation: Elevating the foot to decrease swelling.

Physical Therapy and Rehabilitation Exercises

Physical therapy is a cornerstone of treating Peroneal Tendinopathy. A therapist may employ a variety of techniques, including:

  • Stretching exercises: To improve flexibility in the muscles around the ankle and reduce tension on the tendons.
  • Strengthening exercises: Focused on the lower leg and ankle muscles to improve support for the tendons.
  • Balance and proprioception training: To enhance stability and prevent future injuries.

Orthotic Devices and Supportive Footwear

  • Orthotic devices: Custom or over-the-counter orthotics can provide support, redistribute pressure away from the affected tendons, and correct underlying biomechanical issues.
  • Supportive footwear: Shoes with adequate support and cushioning can help alleviate pain and protect the tendons from further stress.

Medications and Injections for Pain Management

  • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Medications like ibuprofen can reduce pain and swelling during the initial stages.
  • Corticosteroid injections: May be considered to reduce severe inflammation. However, their use is cautious due to potential risks to tendon health.

Surgical Treatment Options

Surgery is considered for Peroneal Tendinopathy when non-surgical treatments fail to relieve symptoms after a significant period, usually several months. Surgical options aim to repair the damaged tendon, remove inflamed tissue, or correct any biomechanical issues contributing to the tendinopathy. Common procedures include:

  • Debridement and repair: Removing the damaged section of the tendon and repairing the remaining tendon.
  • Tendon transfer: In cases where the tendon is severely damaged, part of another tendon is used to replace it.
  • Groove deepening: If the tendons are not stable in their groove behind the fibula, deepening the groove can help stabilise them.

The choice of surgery depends on the extent of tendon damage, the patient’s activity level, and overall health. Post-surgery, a period of immobilisation followed by physical therapy is critical for a successful recovery, aiming to restore function and prevent recurrence.

Preventative Measures

Preventing Peroneal Tendinopathy involves a proactive approach to maintaining foot and ankle health. Here are strategies that can help:

  • Gradual Increase in Activity: Avoid sudden increases in exercise intensity or duration to minimise stress on the peroneal tendons.
  • Proper Warm-Up: Engaging in appropriate warm-up exercises before physical activity can prepare the tendons for the stress to come.
  • Cross-Training: Incorporating low-impact exercises, such as swimming or cycling, can help maintain fitness while reducing stress on the tendons.

Importance of Proper Footwear and Orthotic Support

Selecting the right footwear is crucial in preventing Peroneal Tendinopathy. Shoes should provide adequate support, have a proper fit, and offer cushioning to reduce impact forces on the tendons. For individuals with specific foot biomechanics that increase the risk of tendinopathy, orthotic devices can offer additional support and alignment, distributing pressure more evenly across the foot.

Recommended Exercises to Strengthen the Peroneal Tendons

Strengthening exercises for the peroneal tendons and surrounding muscles can enhance stability and prevent injuries. Key exercises include:

  • Ankle Eversion: Using a resistance band, pull the foot outward against the resistance to strengthen the peroneal muscles.
  • Heel Raises: Standing on the edge of a step and raising the heels up and down can strengthen the calf muscles, providing better support for the tendons.
  • Balance Exercises: Standing on one foot or using a balance board can improve proprioception and ankle stability.


Peroneal Tendinopathy, while challenging, can be managed effectively with the right approach. Prevention plays a key role, emphasising the importance of proper footwear, orthotic support, and targeted exercises. For those living with the condition, a combination of non-surgical treatments and lifestyle adjustments can lead to significant improvements. Always consult with a healthcare professional to tailor the treatment and prevention strategies to your specific needs, ensuring the best possible outcome.